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Medicare Mulls End-of-Life Query for Home Care Pilot

By Kerry Young, CQ Roll Call

July 8, 2015 -- Medicare said it expects to expand use of advance medical directives, which include end-of-life planning, as part of a test program involving home health agencies in nine states. 

"Advance care planning ensures that the health care plan is consistent with the patient's wishes and preferences," the Centers for Medicare and Medicaid Services (CMS) said in a proposed 2016 payment rule for home health services, which outlined plans for a value-based purchasing model. "Increased advance care planning among the elderly is expected to result in enhanced patient autonomy and reduced hospitalizations and in-hospital deaths."

CMS' actions on advance care planning are being closely watched this week. The Office of Management and Budget (OMB) recently completed its review of CMS' proposed 2016 physician reimbursement rule. The document is seen as a likely vehicle for reimbursing doctors for time they spend counseling Medicare beneficiaries about treatment options when facing terminal illness or rapid declines in health. CMS hasn't said when the proposal physician payment rule will be publicly released.

Any outcome is likely to draw some criticism. In the past year, the agency has faced calls from groups such as AARP and the American Medical Association to create a new payment for advance care planning. The groups, along with lawmakers in both parties and chambers, likely will be disappointed if the rule doesn't establish this payment. But there has been continued criticism of the approach, which was linked to "death panels" during the debate over the 2010 health law. The conservative Alliance Defending Freedom remains among those opposed to the idea, and thus likely critics of a proposed new payment. 

The discussion of advance care planning in connection with the new test program was part of CMS' proposed 2016 payment rule for home health agencies, released July 6. CMS listed more than two dozen quality measures that would be used in judging the performance of agencies and organizations participating in the Home Health Value-Based Purchasing program. These providers of home health services could see their payments increased or reduced as much as 8 percent by how their performance is judged.

Among the measures is a check by home health workers of whether patients over 65 have advance care plans, with these seen as mapping their wishes and preferences for treatment.
Home health workers would report whether such a plan was included in the patient's records or if a surrogate, such as a family member or friend, had been identified to make these decisions if needed. The workers would also note cases where the patient opted to decline these discussions.

This work is meant to allow patients a chance to plan for the "what ifs" that can occur in terms of their health, CMS said. Advocates for advance care plans have long argued that this approach spares family members and friends from having to guess how a loved one would want to be treated when that person may be too ill to participate in these decisions. Advance care directives allow patients to make clear that they want every medical intervention possible provided to them, or state that they don't wish to undergo certain treatments, such as ventilation, when nearing death.

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